ORIGINAL ARTICLE

Respiratory Diseases

DOI: 10.3346/jkms.2011.26.2.268 J Korean Med Sci 2011; 26: 268-273

The Risk of Obstructive Lung Disease by Previous Pulmonary

Tuberculosis in a Country with Intermediate Burden of
Tuberculosis
Sei Won Lee1, Young Sam Kim 2, We evaluated the effects of previous pulmonary tuberculosis (TB) on the risk of obstructive
Dong-Soon Kim3, Yeon-Mok Oh3, lung disease. We analyzed population-based, the Second Korea National Health and
and Sang-Do Lee 3 Nutrition Examination Survey 2001. Participants underwent chest X-rays (CXR) and
1
spirometry, and qualified radiologists interpreted the presence of TB lesion independently.
Department of Internal Medicine, Seoul National
University Bundang Hospital, Seongnam; A total of 3,687 underwent acceptable spirometry and CXR. Two hundreds and ninty four
2
Department of Internal Medicine, Yonsei University subjects had evidence of previous TB on CXR with no subjects having evidence of active
College of Medicine, Seoul; 3Department of disease. Evidence of previous TB on CXR were independently associated with airflow
Pulmonary and Critical Care Medicine, and Clinical obstruction (adjusted odds ratios [OR] = 2.56 [95% CI 1.84-3.56]) after adjustment for
Research Center for Chronic Obstructive Airway
Diseases, Asan Medical Center, University of Ulsan sex, age and smoking history. Previous TB was still a risk factor (adjusted OR = 3.13 [95%
College of Medicine, Seoul, Korea CI 1.86-5.29]) with exclusion of ever smokers or subjects with advanced lesion on CXR.
Among never-smokers, the proportion of subjects with previous TB on CXR increased as
Received: 6 August 2010 obstructive lung disease became more severe. Previous TB is an independent risk factor for
Accepted: 26 October 2010
obstructive lung disease, even if the lesion is minimal and TB can be an important cause of
Address for Correspondence: obstructive lung disease in never-smokers. Effort on prevention and control of TB is crucial
Yeon-Mok Oh, MD in reduction of obstructive lung disease, especially in countries with more than
Department of Pulmonary and Critical Care Medicine, and
Clinical Research Center for Chronic Obstructive Airway intermediate burden of TB.
Diseases, Asan Medical Center, University of Ulsan College of
Medicine, 86 Asanbyeongwon-gil, Songpa-gu, Seoul 138-736,
Korea Key Words: Tuberculosis; Lung Diseases, Obstructive
Tel: +82.2-3010-3136, Fax: +82.2-3010-6968
E-mail: ymoh55@amc.seoul.kr
This study was supported by a grant from the Korea Healthcare
Technology R&D Project, Ministry for Health, Welfare and
Family Affairs, Republic of Korea (A040153).

INTRODUCTION
Tuberculosis (TB) and chronic obstructive pulmonary disease
(COPD) are major public health problems worldwide. Despite
intensive global efforts, the total number of new TB cases is still
increasing, with 9.27 million new cases and 1.78 million deaths
in 2006 (1). The mortality rate of COPD is also increasing, and
more than three million people worldwide were estimated to die
from COPD in 2005 (2). About 80 million people worldwide are
estimated to have moderate-to-severe COPD. Several previous
reports have suggested an association between these two diseas-
es. There is a high and increasing prevalence of obstructive lung
disease in patients who are being treated for pulmonary TB (3).
A previous epidemiological study found that the prevalence of
COPD may be different in subjects with and those without a
history of TB (4). Another population-based study found that a
history of TB is closely associated with airflow obstruction (5).
Although some previous studies have shown an association
of TB and obstructive lung disease, most of these studies had
small sample sizes and did not totally exclude the effect of smok-
ing, a potential and strong confounding factor. Smoking is a ma-
jor cause of COPD (6) and also increases the risk of developing
TB (7). In most studies, a medical history of TB is based on self-
reporting, a method limited by recall bias. Patients with sponta-
neously healed TB will not report a history of TB, and that can be
the cause of underestimation on the presence of TB (8). There-
fore, a previous TB should be also evaluated by chest imaging.
In the present study, we evaluated the risk attributable to pul-
monary TB on the development of obstructive lung disease. We
performed nationwide representative sampling in Korea, a coun-
try with an intermediate TB burden. We also evaluated the risk
in patients with minimal TB lesions, and in patients who have
never smoked.
MATERIALS AND METHODS
Data collection
We analyzed the Second Korea National Health and Nutrition

2011 The Korean Academy of Medical Sciences. pISSN 1011-8934

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0)
which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. eISSN 1598-6357
Lee SW, et al. Tuberculosis and Obstructive Lung Disease

Examination Survey (KNHANES II) 2001 data that were prospec- on CXR was defined as the presence of discrete linear or reticu-
tively collected in 2001 by the Korea Institute for Health and So- lar fibrotic scars, or dense nodules with distinct margins, with
cial Affairs. Based on the 2000 Population Census of the Nation- or without calcification, within the upper lobes. Based on CXR
al Statistical Office of Korea, a stratified, multi-stage, clustered, findings, we categorized the TB lesion of each subject as mini-
probability design was used to select a representative sample of mal, moderately advanced, or far-advanced, based on the clas-
civilian, non-institutionalized Korean adults aged 18 yr and old- sification of the National Tuberculosis and Respiratory Disease
er. Trained interviewers visited subjects homes and adminis- Association of the USA (14).
tered standardized questionnaires to determine health status.
Statistical analysis
Pulmonary function test Comparisons between variables were tested using the chi-square
Spirometry was conducted by trained pulmonary technicians test or Students t-test. We constructed a logistic regression mod-
according to the 1994 American Thoracic Society (ATS) recom- el with obstructive lung disease as the dependent variable and
mendations (9), using Dry Rolling-seal spirometry (Vmax-2130, age, sex, smoking history (more than 2 weeks), and TB lesions
Sensor-Medics, Yorba Linda, CA, USA). The electronically gen- on CXR as independent variables. A forward selection method
erated spirometric data were transferred via the internet to the was used to exclude multi-colinearity of each variable. Odds ra-
review center on the same day. Two trained nurses reviewed the tios (ORs) were calculated with PASW 17.0 (SPSS Inc., Chicago,
test results and provided quality control feedback to the techni- IL, USA).
cians. All data were saved for further analysis. Even though the
ATS recommendations require three or more acceptable curves Ethics statement
for an adequate test, this is not practical for a large-scale exami- The institutional review board of the Asan Medical Center (Seoul,
nation survey, so we analyzed only the data of subjects with two Korea) approved this analysis of the Korean population, which
or more acceptable spirometry performances (10). The predict- was prospectively collected. Informed consent was obtained
ed forced expiratory volume in one second (FEV1) and forced from all subjects during the initial data collection.
vital capacity (FVC) were derived from the survey data of life-
time nonsmoking subjects with normal chest radiographs and RESULTS
no history of respiratory disease or symptoms (11). Airflow ob-
struction was defined as FEV1/FVC less than 70% (6) or lower Characteristics of enrolled subjects
limit of normal (LLN) (12). Among 9,243 subjects (> 18 yr old), 8,209 (88.8%) responded to
the questionnaires, 4,479 (48.5%) completed spirometry and
Chest radiograph (CXR) CXR; and 3,687 (39.9%) subjects underwent at least two spirom-
CXR images were taken in specially-equipped mobile exami- etry measurements acceptable by ATS criteria with chest radio-
nation cars at the time of spirometry. Two qualified radiologists graph data (we analyzed these subjects). Although there was
evaluated CXRs independently using standard criteria for report- significant difference in age distribution between subjects en-
ing of radiological abnormalities (13). If there was disagreement rolled and excluded, the pattern of sex, smoking status, respira-
about interpretation of a CXR, the two radiologists discussed tory symptoms, physician based diagnosis of COPD and asth-
this with a third radiologist and reached a consensus. TB lesion ma, and mean age (43.4 yr in enrolled vs 43.1 yr in excluded, P =
0.33) were similar, suggesting the data were representative (Table
Table 1. General characteristics of the subjects
1). Among 3,687 enrolled for analysis, radiologists concluded
Subjects enrolled Subjects excluded that 294 (8.0%) subjects were classified as having TB lesion on
Parameters P value
(n = 3,687) (n = 4,522)
CXR. All TB lesions were classified as inactive and there was no
Age (yr): No. (%)
subject with lesion indicative of active TB on CXR. Two hundreds
18-34 1,098 (29.8) 1,672 (37.0)
35-54 1,693 (45.9) 1,740 (38.5)
55-74 838 (22.7) 866 (19.2) Table 2. Pulmonary function of subjects with or without TB lesion on CXR
75 58 (1.2) 244 (5.4) < 0.001
Male: No. (%) 1,694 (45.9) 2,055 (45.4) 0.66 Subjects with Subjects without
Parameters P value
TB lesion (n = 294) TB lesion (n = 3,393)
Smoking status
Never: No. (%) 2,270 (62.4) 2,279 (61.2) FVC (L) 3.81 0.95 3.88 0.94 0.22
Ever: No. (%) 1,385 (37.6) 1,750 (38.8) 0.28 FVC (%pred) 94.9 13.5 98.3 12.0 < 0.001
20 pack-year: No. (%) 463 (12.7) 565 (12.6) 0.95 FEV1 (L) 2.83 0.83 3.16 0.80 < 0.001
Cough: No. (%) 46 (1.3) 47 (1.1) 0.40 FEV1 (%pred) 89.5 17.0 97.2 13.1 < 0.001
Sputum: No. (%) 92 (2.6) 85 (1.9) 0.06 FEV1/FVC (%) 74.3 10.8 81.6 7.8 < 0.001
Dx of COPD or asthma 128 (3.5) 156 (3.5) 0.98
CXR, chest X-rays; TB, tuberculosis; %pred, % of predicted value; FVC, forced vital
Dx, physician diagnosis; COPD, chronic obstructive pulmonary disease. capacity; FEV1, forced expiratory volume in one second.

DOI: 10.3346/jkms.2011.26.2.268 http://jkms.org 269

 Lee SW, et al. Tuberculosis and Obstructive Lung Disease

and ninty subjects had minimal lesions and four subjects had
moderately or far-advanced lesions. Initial interpretation be-
tween two radiologists about the presence of TB lesion showed
almost perfect agreement ( = 0.95, P < 0.001) with 99.3% of agree-
ment rate. There were characteristic differences in sex, age and
number of smokers between subjects with and without TB lesion
on CXR. Group with TB lesion on CXR had higher mean age
(53.3 14.0 yr vs 42.5 14.0 yr, P < 0.001), more male sex (184/
294 [62.6%] vs 1,510/3,393 [44.5%], P < 0.001) and more smok-
ers (156/294 [53.1%] vs 1,229/3,393 [36.2%], P < 0.001).
FVC < 0.70 and 2.64 (95% CI = 1.97-3.52) by FEV1/FVC < LLN.
After excluding subjects with smoking histories and subjects
with moderate or far-advanced TB lesions (n = 2,298), minimal
TB lesions on CXR remained associated with airflow obstruc-
tion, with adjusted ORs of 3.13 (95% CI = 1.86-5.29) by the defi-
nition of airflow obstruction FEV1/FVC < 0.70 and 4.02 (95% CI
= 2.54-6.36) by FEV1/FVC < LLN (Table 3).
P for trend < 0.001
P = 0.01

Pulmonary function as the presence of TB lesion on CXR 35 34.0%

Proportion of subjects with previous

Subjects with TB lesion had relatively lower FVC per predicted
30
value (94.9 13.5% vs 98.3 12.0%, P < 0.001), FEV1 (2.83 0.83L
vs 3.16 0.80, P < 0.001), FEV1 per predicted value (89.5 17.0% 25
vs 97.2 13.1, P < 0.001) and FEV1/FVC (74.3 10.8% vs 81.6 P = 0.002

lesion (%)
20
7.8, P < 0.001), compared with those without TB lesion on CXR. 14.3%
15
FVC did not show significant difference between two groups
(Table 2). 10
5.2%
5
The risk of airflow obstruction by TB lesions on CXR
Based on univariate analysis, male sex, age, smoking history, 0
FEV1/FVC 0.7 FEV1 80%Pred FEV1 < 80%Pred
and TB lesions were associated with airflow obstruction. After FEV1/FVC < 0.7
adjustment for sex, age, smoking history, TB lesions on CXR were
Fig. 1. Proportion of subjects with TB lesion as the severity of airflow obstruction. %
still associated with airflow obstruction. Adjusted ORs were 2.56 Pred, % of predicted value; TB, tuberculosis; FVC, forced vital capacity; FEV1, forced
(95% CI = 1.84-3.56) by the definition of airflow obstruction FEV1/ expiratory volume in one second.

Table 3. Risks of airflow obstruction by previous TB. Odd Ratios are analyzed in all enrolled subjects and in never smokers with exclusion of subjects with advanced TB lesion,
separately
Airflow obstruction defined as FEV1/FVC < 0.70 Airflow obstruction defined as FEV1/FVC < LLN

Parameters No. (%) No. (%)

Crude OR Adjusted* OR Crude OR Adjusted* OR
with airflow with airflow
(95% CI) (95% CI) (95% CI) (95% CI)
obstruction obstruction
All enrolled subjects 3,687 3,668 (100)
TB lesion
No previous TB 3,393 219 (6.5) 376 (11.1)
Previous TB 294 82 (27.9) 5.61 (4.20-7.49) 2.56 (1.84-3.56) 89 (30.3) 3.46 (2.64-4.54) 2.64 (1.97-3.52)
Smoking
Never 2,300 109 (4.7) 175 (7.7)
Ever 1,387 192 (13.8) 3.23 (2.53-4.13) 1.88 (1.31-2.72) 290 (21.0) 3.21 (2.62-3.92) 2.18 (1.62-2.94)
Sex
Female 1,993 87 (4.4) 146 (7.4)
Male 1,694 214 (12.6) 3.17 (2.45-4.10) 2.12 (1.44-3.11) 319 (18.9) 2.94 (2.38-3.61) 1.56 (1.15-2.13)
Age 2.34 (2.12-2.58) 2.30 (2.07-2.54) 1.19 (1.11-1.27) 1.12 (1.04-1.20)
Never smokers with exclusion 2,300 2,287 (100)
of subjects with advanced
TB lesion
TB lesion
No previous TB 2,162 84 (3.9) 146 (6.8)
Previous TB 138 25 (18.1) 5.47 (3.37-8.89) 3.13 (1.86-5.29) 29 (21.0) 3.65 (2.35-5.68) 4.02 (2.54-6.36)
Sex
Female 1,894 79 (4.2) 135 (7.2)
Male 406 30 (7.4) 1.83 (1.19-2.83) 1.73 (1.09-2.76) 40 (9.9) 1.42 (0.98-2.06) 1.36 (0.94-1.98)
Age 2.15 (1.85-2.50) 2.05 (1.75-2.39) 0.95 (0.85-1.05) 0.89 (0.80-1.00)
*Adjusted for TB lesion on CXR, smoking history, sex and age; Subjects without data of height and weight were excluded in analysis; Previous TB was defined by TB lesions
on chest X-ray; Odds ratio as age increased by 10 yr. TB, tuberculosis; LLN, lower limit of normal; FVC, forced vital capacity; FEV1, forced expiratory volume in one second; OR,
odds ratio; CI, confidence interval.

270 http://jkms.org DOI: 10.3346/jkms.2011.26.2.268

Lee SW, et al. Tuberculosis and Obstructive Lung Disease
Subjects with TB lesions as severity of airflow obstruction
among never smokers
Among never smokers, the proportion of subjects with TB lesions
increased as the severity of obstructive lung disease increased
(P for trend < 0.001). A total of 113 (5.2%) of 2,190 subjects with-
out airflow obstruction (FEV1/FVC > 0.7) had TB lesions. Among
subjects with airflow obstruction, 9 (14.3%) of 63 subjects with
FEV1 80% of predicted values, 16 (34.0%) of 47 with FEV1 < 80%
of predicted values had TB lesions (Fig. 1).
DISCUSSION
In this study, based on a nationwide representative sampling of
Korean subjects, we found that previous TB was a risk factor for
obstructive lung disease and even a minimal TB lesion was an
also strong risk factor in never smokers. The proportions of sub-
jects with previous TB lesion increased as the severity of obstruc-
tive lung disease, suggesting previous TB is an important contrib-
uting factor for obstructive lung disease among never smokers.
Previous studies have suggested that pulmonary TB is associ-
ated with obstructive lung disease. Patients with previous pul-
monary TB were more likely to suffer from acute exacerbation
of COPD than those who did not have pulmonary TB (15). In
silicosis patients, history of TB is an independent predictor of
airflow obstruction (16). The bronchodilator response of pa-
tients with a tuberculous-destroyed lung is lower than that of
patients with COPD (17). Airflow impairment is related to the
radiological extent of TB (3) and to the number of TB episodes.
However, most of these studies had small sample sizes, were
not population-based, or did not fully adjust for smoking histo-
ry. A smoking history could potentially have biased the estimat-
ed effect of TB on loss of lung function. A previous study found
that smoking history is associated with an increased risk of TB
for a cohort of white gold miners, and smoking is known to in-
crease lung function loss (18). Recently, a population-based
study of Latin American middle-aged and older adults found
that previous medical diagnosis of TB was associated with air-
flow obstruction (5). A cohort study showed that radiologic evi-
dence of inactive TB was associated with increased risk of air-
flow obstruction, although it was not population-based (8).
A history of TB may affect lung function by pleural change,
bronchial stenosis, or parenchymal scarring. TB increases the
activity of the matrix metalloproteinases, thus contributing to
pulmonary damage (19). Extensive TB lesions may produce re-
strictive changes, with reduced transfer of carbon monoxide in
the lung (20). However, we found that the presence of minimal
lesions was also an independent risk factor for airflow obstruc-
tion. In these patients, airway fibrosis and inflammation may
play important roles. TB infection is associated with airway fibro-
sis and the immune response to mycobacteria could cause air-
way inflammation, a characteristic of obstructive lung disease
DOI: 10.3346/jkms.2011.26.2.268
(21).
Smoking is a well-established major risk factor for COPD (22)
and much COPD research has focused on smokers (23). How-
ever, recent evidence suggests that other risk factors are also im-
portant in causing obstructive lung disease, especially in devel-
oping countries. These factors include air pollutants, dust and
fumes, history of repeated lower respiratory tract infections dur-
ing childhood, chronic asthma, intrauterine growth retardation,
poor nourishment, and poor socioeconomic status. Several ques-
tionnaire studies have also suggested that a history of TB is a risk
factor for airflow obstruction (24, 25). In our study, 22.7% (25/
110) of never smokers with airflow obstruction had TB lesions,
and the proportion increased for subjects with FEV1 < 80% of
predicted value. This suggests that previous TB can be an impor-
tant cause of obstructive lung disease among never smokers.
In this study, we defined airflow obstruction as FEV1/FVC
less than 0.70 or LLN. Although a fixed ratio of 0.70 is simple and
widely used, it is criticized due to over-diagnosis of both the pres-
ence and severity of COPD in the elderly (26). TB lesion on CXR
was still associated with airflow obstruction (adjusted OR = 2.66,
95% CI 1.99-3.55, P < 0.001) and it is consistent in never smok-
ers (adjusted OR = 4.02, 95% CI 2.54-6.36, P < 0.001), when we
defined obstructive lung disease by LLN. We enrolled subjects
with two or more acceptable spirometry performances for prac-
tical consideration of a large-scale examination survey. ATS and
European Respiratory Society (ERS) recommendations was pub-
lished after this survey, requiring three or more acceptable cur
ves for an adequate test with the differance in the two largest
values of FVC or FEV1 < 0.150 L (27). When we adopted this rec-
ommendation (n = 2,533), TB lesion on CXR was still associated
with airflow obstruction (FEV1/FVC < 0.70) with adjusted OR =
2.20, 95% CI 1.44-3.35, P < 0.001) and it was also consistent in
never smokers (adjusted OR = 3.38, 95% CI 1.75-6.55, P = 0.001).
This study has some limitations. First, airflow obstruction was
defined by FEV1/FVC rather than post-bronchodilator FEV1/FVC.
This might lead to an overestimate of the prevalence of obstruc-
tive lung disease. However, our estimates are similar to those of
previous studies. Second, previous TB was only evaluated by
CXR and clinical history was not examined. From a specificity
point of view, a lesion that seems to be TB-related on CXR could
be a sequela of other diseases such as pneumonia. From a view
of sensitivity, CXR could miss some parenchymal TB lesions,
which can only be identified by computed tomography (CT)
analysis (28, 29). In addition, some TB patients might have had
complete healing without any evidence on the CXR. Although
CXR has limitations in confirming previous TB, in the present
study 3 qualified radiologists interpreted the CXRs to reduce this
limitation and interpretation on CXRs of radiologists showed
almost perfect agreement. Third, there was relatively large num-
ber of subjects with TB lesion on CXR (8.0%), compared with
the number of TB reports in Korea (30). In other study, the prev-
http://jkms.org 271

alence of prior TB based on self-reports (2.9%) was also signifi-
cantly lower than that defined by CXR (24.2%) (8). Considering
this discrepancy between radiologic evidence and self-report of
TB and continuously decreasing annual incidence in Korea, our
interpretations of TB lesion on CXR do not seem to go beyond
reasonable level. Fourth, there were only four subjects with ad-
vanced TB lesion. In this survey, subjects should visit a car with
special equipment to undergo spirometry. Therefore, the possi-
bility of selection bias, to enroll relatively healthy subjects main-
ly, cannot be excluded.
In conclusion, previous TB was an independent risk factor
for obstructive lung disease, even if the lesions are minimal. TB
could be also an important cause of airflow obstruction in sub-
jects who had never smoked. The results of this population-based
study indicated that appropriate management and control of
TB is as important as smoking quitting for reducing obstructive
lung disease.
REFERENCES
1. World Health Organization. Global tuberculosis control: surveillance,
planning, financing. WHO report 2007. Report No.: (WHO/HTM/TB/
2007.376). Available at http://www.who.int/tb/publications/global_re-
port/ 2007/pdf/full.pdf [accessed on 11 Feb 2010].
2. World Health Organization. Chronic obstructive pulmonary disease,
Burden, 2008. Available at http://www.who.int/respiratory/copd/bur-
den/en/index.html [accessed on 17 Sep 2009].
3. Willcox PA, Ferguson AD. Chronic obstructive airways disease following
treated pulmonary tuberculosis. Respir Med 1989; 83: 195-8.
4. Kim SJ, Suk MH, Choi HM, Kimm KC, Jung KH, Lee SY, Lee SY, Kim JH,
Shin C, Shim JJ, In KH, Kang KH, Yoo SH. The local prevalence of COPD
by post-bronchodilator GOLD criteria in Korea. Int J Tuberc Lung Dis
2006; 10: 1393-8.
5. Menezes AM, Hallal PC, Perez-Padilla R, Jardim JR, Muio A, Lopez
MV, Valdivia G, Montes de Oca M, Talamo C, Pertuze J, Victora CG; Lat-
in American Project for the Investigation of Obstructive Lung Disease
(PLATINO) Team. Tuberculosis and airflow obstruction: evidence from
the PLATINO study in Latin America. Eur Respir J 2007; 30: 1180-5.
6. Global Institute for Chronic Obstructive Lung Disease. Workshop report:
global strategy for diagnosis, management, and prevention of COPD.
Geneva, Switzerland 2008. Available at http://www.goldcopd.org [ac-
cessed on 17 Sep 2009].
7. Lowe CR. An association between smoking and respiratory tuberculosis.
Br Med J 1956; 2: 1081-6.
8. Lam KB, Jiang CQ, Jordan RE, Miller MR, Zhang WS, Cheng KK, Lam
TH, Adab P. Prior tuberculosis, smoking and airflow obstruction: a cross-
sectional analysis of the Guangzhou Biobank Cohort Study. Chest 2010;
137: 593-600.
9. American Thoracic Society. Standardization of Spirometry, 1994 Up-
date. American Thoracic Society. Am J Respir Crit Care Med 1995; 152:
1107-36.
10. Kim DS, Kim YS, Jung KS, Chang JH, Lim CM, Lee JH, Uh ST, Shim JJ,
Lew WJ; Korean Academy of Tuberculosis and Respiratory Diseases.
272 http://jkms.org
Lee SW, et al. Tuberculosis and Obstructive Lung Disease
Prevalence of chronic obstructive pulmonary disease in Korea: a popula-
tion-based spirometry survey. Am J Respir Crit Care Med 2005; 172: 842-7.
11. Choi JK, Paek D, Lee JO. Normal predictive values of spirometry in Kore-
an population. Tuberc Respir Dis 2005; 58: 230-42.
12. Hwang YI, Kim CH, Kang HR, Shin T, Park SM, Jang SH, Park YB, Kim
CH, Kim DG, Lee MG, Hyun IG, Jung KS. Comparison of the prevalence
of chronic obstructive pulmonary disease diagnosed by lower limit of
normal and fixed ratio criteria. J Korean Med Sci 2009; 24: 621-6.
13. The United States of America Department of State. Instruction to panel
for completing chest X-ray and classification worksheet (DS-3024). Avail-
able at http://www.cdc.gov/ncidod/dq/dsforms/3024.htm [accessed on
26 Nov 2009].
14. Falk AJ, OConnor B, Pratt PC. Classification of pulmonary tuberculosis.
12th ed. New York: National Tuberculosis and Respiratory Disease Asso-
ciation; 1969.
15. Mohan A, Premanand R, Reddy LN, Rao MH, Sharma SK, Kamity R,
Bollineni S. Clinical presentation and predictors of outcome in patients
with severe acute exacerbation of chronic obstructive pulmonary disease
requiring admission to intensive care unit. BMC Pulm Med 2006; 6: 27.
16. Leung CC, Chang KC, Law WS, Yew WW, Tam CM, Chan CK, Wong MY.
Determinants of spirometric abnormalities among silicotic patients in
Hong Kong. Occup Med (Lond) 2005; 55: 490-3.
17. Lee JH, Chang JH. Lung function in patients with chronic airflow obstruc-
tion due to tuberculous destroyed lung. Respir Med 2003; 97: 1237-42.
18. Hnizdo E, Murray J. Risk of pulmonary tuberculosis relative to silicosis
and exposure to silica dust in South African gold miners. Occup Environ
Med 1998; 55: 496-502.
19. Elkington PT, Friedland JS. Matrix metalloproteinases in destructive pul-
monary pathology. Thorax 2006; 61: 259-66.
20. Hallett WY, Martin CJ. The diffuse obstructive pulmonary syndrome in a
tuberculosis sanatorium. I. Etiologic factors. Ann Intern Med 1961; 54:
1146-55.
21. Salvi SS, Barnes PJ. Chronic obstructive pulmonary disease in non-smok-
ers. Lancet 2009; 374: 733-43.
22. Fletcher C, Peto R. The natural history of chronic airflow obstruction. Br
Med J 1977; 1: 1645-8.
23. Tzanakis N, Anagnostopoulou U, Filaditaki V, Christaki P, Siafakas N;
COPD group of the Hellenic Thoracic Society. Prevalence of COPD in
Greece. Chest 2004; 125: 892-900.
24. Ehrlich RI, White N, Norman R, Laubscher R, Steyn K, Lombard C, Brad-
shaw D. Predictors of chronic bronchitis in South African adults. Int J
Tuberc Lung Dis 2004; 8: 369-76.
25. Caballero A, Torres-Duque CA, Jaramillo C, Bolvar F, Sanabria F, Oso-
rio P, Orduz C, Guevara DP, Maldonado D. Prevalence of COPD in five
Colombian cities situated at low, medium, and high altitude (PREPOCOL
study). Chest 2008; 133: 343-9.
26. Hardie JA, Buist AS, Vollmer WM, Ellingsen I, Bakke PS, Mrkve O. Risk
of over-diagnosis of COPD in asymptomatic elderly never-smokers. Eur
Respir J 2002; 20: 1117-22.
27. Miller MR, Hankinson J, Brusasco V, Burgos F, Casaburi R, Coates A,
Crapo R, Enright P, van der Grinten CP, Gustafsson P, Jensen R, John-
son DC, MacIntyre N, McKay R, Navajas D, Pedersen OF, Pellegrino R,
Viegi G, Wanger J; ATS/ERS Task Force. Standardisation of spirometry.
Eur Respir J 2005; 26: 319-38.
28. Lee KS, Im JG. CT in adults with tuberculosis of the chest: characteristic
DOI: 10.3346/jkms.2011.26.2.268
Lee SW, et al. Tuberculosis and Obstructive Lung Disease

findings and role in management. AJR Am J Roentgenol 1995; 164: 1361-7. 30. The Korea Centers for Disease Control and Prevention. Annual report
29. Kim HJ, Lee HJ, Kwon SY, Yoon HI, Chung HS, Lee CT, Han SK, Shim on the notified tuberculosis patients in Korea. Available at http://tbnet.
YS, Yim JJ. The prevalence of pulmonary parenchymal tuberculosis in cdc.go.kr/rv/TBC_Gnss_Sttst_LN.dm [accessed on 30 Sep 2009].
patients with tuberculous pleuritis. Chest 2006; 129: 1253-8.

AUTHOR SUMMARY

The Risk of Obstructive Lung Disease by Previous Pulmonary Tuberculosis in a

Country with Intermediate Burden of Tuberculosis
Sei Won Lee, Young Sam Kim, Dong-Soon Kim, Yeon-Mok Oh, and Sang-Do Lee

We evaluated the effects of previous pulmonary tuberculosis (TB) on the risk of obstructive lung disease. We analyzed population-
based, the Second Korea National Health and Nutrition Examination Survey 2001. Participants underwent chest X-rays (CXR) and
spirometry, and qualified radiologists interpreted the presence of TB lesion independently. Among 3,687 participants, 294 subjects
had evidence of previous TB on CXR. Evidence of previous TB on CXR were independently associated with airflow obstruction (odds
ratios = 2.56, 95% CI 1.84-3.56) after adjustment for sex, age and smoking history. Previous TB was still a risk factor with
exclusion of ever smokers or subjects with advanced lesion on CXR. Previous TB is an independent risk factor for obstructive lung
disease, even if the lesion is minimal and TB can be an important cause of obstructive lung disease in never smokers.

DOI: 10.3346/jkms.2011.26.2.268 http://jkms.org 273